NCM 112- CARE OF CLIENTS WITH

PROBLEMS IN CELLULAR
ABERRATIONS

By:

JOSEPHINE B. MAGNO, RN, MN

BEHAVIORAL OBJECTIVES:

⚫ Distinguish terms related to the concept;

⚫ illustrate the normal structure and function of the cell;
⚫ differentiate phases of cellular mitosis;
⚫ validate changes that occur in cancerous cells and their functional significance;
⚫ compare the normal cell from the malignant cell;
⚫ outline factors that contribute to cancer development;
⚫ categorize the different stages of cancer development;
⚫ contrast between benign and malignant tumor;
⚫ cite method for naming and classifying tumors;
⚫ validate the clinical manifestations of cancer;
⚫ propose the significance of health education and preventive care in lowering the incidence of cancer;
⚫ organize ways of preventing cancer;
⚫ recommend the importance of identifying the different laboratory examinations and the corresponding
nursing management;
⚫ appraise the roles of surgery, chemotherapy, and radiation in treating cancer;
⚫ prioritize the nursing needs of clients according to the type of therapy received;
⚫ illustrate other treatment modalities in treating cancer;
⚫ describe briefly the cancer involving the specific site or organ in the body; and
⚫ formulate common nursing diagnoses and collaborative problems of patients with cancer.
⚫ apply nursing process in formulating care plan for client with cancer.
Cancer
- a disease process whereby cells proliferate abnormally, ignoring-regulating signals in the environment
surrounding cells.

DEFINITION OF TERMS:

Aberrant Cellular Growth- it is an alteration in the normal cellular growth which occurs when the cells
escape the normal control in growth and differentiation.

Apoptosis – programmed cellular death.

Cyst- a closed sac having a distinct membrane and developing abnormally in a body cavity or structure

Metastasis- it is the spread of cancer cells from the primary tumor to distant sites.

Neoplasm- Greek: NEO “new”, Plasia “growth of tissue”

- an abnormal mass of tissue that serves no useful purpose and may harm the host organism.
- a mass of new tissue that grows independently of its surrounding structures
and has no physiologic purpose.

Carcinoma - a specific form of cancer or malignant tumor arising from epithelial cells.
(In Greek "Epi" means, "on, upon," and "Theli" meaning "tissue. “)

Tumor - it is a lump, mass, or swelling or enlargement; solid neoplasm

Sarcoma - a malignant tumor arising from non-epithelial tissue.

Oncogenes - inducing genes; genes that promote cell proliferation and are capable of triggering
cancerous characteristics

Oncology- the field or study of cancer; a medical specialty that deals with the diagnosis,
treatment and study of cancer.
Proto-oncogenes- these are benign forms of oncogenes necessary for some normal cellular functions,
especially growth and development.

Tumor suppressor gene- genes which inhibit cell division and survival.

Proto-oncogene appear to be normal genes

Behavior may be altered due to

Incorporation of retrovirus Mutation of physical or chemical carcinogen

Transformation

Oncogene
Differentiation – extent to which tissue cells resemble normal cells
- it can be well differentiated or poorly differentiated through cytologic
examination (under the microscope).

Progression – phenomenon by which malignancies attain their function slowly.

Neoplastic Progression- worsening of the cell’s biological potential, with the

passage of time neoplasm becomes more malignant. (very fast mutation)

Carcinoma in Situ- neoplasm which remains confined on the site of origin.

The CELL- is the basic structural and functional unit of living organisms.

Parts of the cell:

1. Cell Membrane- is a fragile, transparent barrier that contains the cell contents and separates them
from the surrounding environment.

2. Cytosol- is a semitransparent fluid that suspends the other elements. Water, nutrients and
variety of other solutes are dissolved in cytosol.

3. Nucleus- considered the “control center” of the cell. It is a large oval body near the
center of the cell which contains DNA. Plays central role in heredity.

4. Ribosomes- are tiny, bilobed, dark bodies made of proteins and one variety of RNA called ribosomal
RNA. The actual site of protein synthesis in the cell occurs in ribosomes. Some ribosomes float free in
the cytoplasm, where they manufacture proteins that function in the cytoplasm. Others attach to
membranes.
5. Endoplasmic Reticulum- serves as a mini circulatory system for the cell because it provides a network
of channels for carrying substances from one part of the cell to another.

⚫ Rough Endoplasmic Reticulum- it has ribosomes, it is especially abundant in cells that make and
export proteins.
⚫ Smooth Endoplasmic Reticulum- has no ribosomes, it functions in lipid
metabolism and detoxification of drugs and pesticides.

6. Golgi Complex- its major function is to modify and package proteins, sent to it by the rough ER via
transport vesicles.

7. Lysosomes- are considered “suicide sacs”, function as the cell’s demolition sites.

8. Mitochondria- it is the powerhouse of the cell; it releases energy for cell functions.

9. Flagella and cilia- are structures that aid in locomotion and help move fluids across the surface of
tissue cells.

The Cell Cycle:

-is the series of changes a cell goes through from the time it is formed until it divides.

Divided into 2 periods:

1. M Phase- which includes nuclear division (mitosis) and cell division (cytokinesis)

Phases of Mitotic Cell Division:

⚫ Prophase
⚫ Metaphase
⚫ Anaphase
⚫ Telophase
⚫ Cytokinesis

2. Interphase- part of the cell cycle which is not contained in M phase

Interphase divided into three periods

Interval or Steps
G – gap
M – the interval separating Mitosis
S - synthesis

⚫ Step IA: G0 -interval in which the cell is at rest from cell division.

⚫ Step IB: G1- the cell grows physically larger, copies organelles and makes the molecular building
blocks it will need in later steps.

⚫ Step II: S- the cell synthesizes a complete copy of the DNA in its nucleus.

⚫ Step III: G2- the cell grows more and begins to recognize its contents in preparation for mitosis.

＊Cell growth and reproduction are the most fundamental of all living functions.
Cellular Adaptive Process:

Differentiation
- cells are transformed into different and more specialized cell types as they proliferate from a
single stem cell

It determines:
What cell will look like? How it will function?
How long will it live?

1. Hyperplasia- increase in the number of cells of a tissue; most often associated with periods of
rapid body growth.

2. Metaplasia- it is the conversion of one type of mature cell into another type of cell.

3. Dysplasia- bizarre cell growth resulting in cells that differ in size, shape, or arrangement from
other cells of the same type of tissue.

4. Anaplasia- cells that lack normal cellular characteristics and differ in shape and organization with
respect to their cells of origin; usually, anaplastic cells are malignant.
 DEFINITION
OF OTHER TERMS

ATROPHY

Decrease in cell size

HYPERPLASIA
 Increase in the number of cells

METAPLASIA

Substitution of one cell with other type

HYPERTHROPHY

Increase in cell size

 DYSPLASIA

Deranged cell growth

Cellular Changes:

Contact Inhibition- cessation of growth ones the cell comes in contact with another cell. It switches off cell
growth by blocking the synthesis of DNA, RNA and CHON.
Cell Proliferation – is well regulated, process by which multiply and bear offspring

Types of cells according to their ability to undergo regeneration:

⚫ Labile- GI, skin, stem cells in BM

⚫ Stable- bone, liver cells

⚫ Permanent or Fixed- cardiac muscle cells, brain cells, photoreceptors in retina

FACTORS WHICH CONTRIBUTE TO THE DEVELOPMENT OF CANCER

1. Oncogenic Viruses + oncogene

2. Carcinogens

2.1. Chemical – forms electrophiles (highly reactive ion)

2.1.A. Industrial Compound

⚫ Vinyl Chloride-
- plastic manufacture
- asbestos factories
- construction works

⚫ Polycyclic Aromatic
- DNA damage.
- vehicle emissions
- oil refin
2.1. B. Foods and Preservatives

⚫ Nitrates (can goods)

⚫ Talc (beauty products)
⚫ Food Sweeteners

2.2. Radiation – additive effect (high energy)

1. Ionizing Radiation – cancer induction

2. X-ray- repeated diagnostic x-ray procedures
3. Radioactive Isotopes- radiation therapy used to treat disease
4. Sunlight/ Ultraviolent rays- excessive exposure to UV rays increases risk of skin cancer
5. Radon- decay of Uranium found in soil and rocks; associated with lung cancer
6. Electromagnetic Radiation- associated with higher incidence of cancer

3. Immunologic Defects

4. Age

5. Gender

6. Heredity

7. Poverty

8. Stress

9. Lifestyle Practices
a. Smoking b. Nutrition
c. Obesity
d. Sexual and reproductive factors

Characteristics of Cancer Cells:

1. Anaplasia – used to describe lack of normal cell proliferation and differentiation in AFP stands for alpha-
fetoprotein. It is a protein
cancerous tissue
made in the liver of a
developing
General Rule: baby. AFP levels are
The more undifferentiated the tumor usually high when a baby
Normal – well
is born, but fall to very low
The more frequent the mitosis differentiated levels by the age of 1.
The more rapid the rate of growth Healthy adults should
have very low levels
2. Cell surface and membrane alteration (N- single layer, ABN- pile up) of AFP. An AFP tumor
marker test is a blood test
3. Metabolic Changes that measures the levels
 4. Antigenic Changes (Tumor marker – Blood test of the fetal antigens. of AFP in adults.
↑=positive) e.g. Carcinoembryonic antigen (CEA) or
 angiogenesis

STAGES OF CANCER DEVELOPMENT

1. Initiation- alteration in the structure of cellular DNA.

2. Latency/Promotion- proliferation of abnormal cells due to

repeated exposure of promoting agents (substances that
will promote the growth of an initiated cancer
cell).

3. Progression- exhibit increased malignant behavior, rapid proliferation of cancer cells, Irreversible.
proto oncogene to oncogene to cancer

5. Invasion- process by which malignant cells move through the basement membrane and gain
access to blood vessels and lymphatic channels.

⚫ Regional invasion - cancer cells invade surrounding tissues & organs

⚫ Metastasis - spread to a distant body site
⚫ Route: Vascular, Lymphatic, Surgical
⚫ Regional Invasion occurs by:
A. Cellular proliferation
B. Loss of contact inhibition
C. Secretion of cystic substance
- HYALURONIDASE- destroys intracellular cementic substances

Mechanism of Metastasis:
1. Invasion of Neoplastic cells to adjacent tissues caused by:

⚫ Increasing tumor size.

⚫ Loss of tumor cohesiveness with increasing motility.
⚫ Destruction of the supporting tissues of an organ.
⚫ Factors in the host response to tumor cell invasion.
2. Spread of tumor cells via:
a. Lymphatic system b. Blood vessels
c. Direct expansion of tumors in body cavities

Example:
Ovarian CA – seed the entire peritoneal cavity
CNS CA – spread via gravity in the cerebral site

3. Establishment and growth of tumor cells at the secondary site

https://youtu.be/0OAi4sxScXg ( URL- Overview on CA)

https://youtu.be/P4gz6DrZOOI (URL- Physiology of Cell)

https://youtu.be/g7iA

VCLZWuM (URL- Cell Cycle)

COMPARISON BETWEEN NORMAL AND MALIGNANT CELL

CHARACTERISTICS NORMAL CELL MALIGNANT CELL

MITOTIC DIVISION Leads to 2 daughter cells Leads to multiple daughter cells
APPEARANCE Homogenous in size, shape and growth Larger and grows rapidly than normal,
heterogenous
Cohesive, forms regular patterns of
expansion Not cohesive, irregular pattern of
expansion
Uniform in size to nucleus
Larger, more prominent nucleus
Well differentiated
Lack of pattern in organization
GROWTH PATTERN Do not invade adjacent tissue Invade adjacent tissue

Proliferation in response to specific stimuli Proliferate in response to adnormal stimuli

Grows in ideal condition Grows in adverse condition

Cell birth is equal to cell death Cell birth exceed cell death

Stable cell membranes Loss of control as a result of cell

membrane change
Constant predictable growth rate
Erratic growth rate
Cannot grow out of specific environment
Able to break off cells that migrate through
blood stream/lymphatic channels
FUNCTION Have specific designated purpose No useful purpose

Contribute to overall well-being of the host Parasitic

Function in specific predetermined manner No normal function, causes damage

 instead
OTHERS Chromosomes remain constant throughout Chromosome aberration occur as cells
cell division matures

Cannot invade, erode or spread Invades, erodes, and spreads have own
blood supply
Specific Destructive Enzymes:
1. Collagenases
2. Plasminogen Activators
3. Lysosomal Hydrolyses

Classification of Neoplasm: Tissue of Origin

“OMA” – means tumor

- usually attached to a term for a parent tissue of the tumor

Example: “aden” (gland) + oma = Adenoma

- when one or more parent tissue enters into the formation of neoplasm, the names of a tumor are even more descriptive

Example:
Adenomyoma – benign neoplasm that contains both glandular & myoma cells

3 Most Common Benign Tumors

1. Fibroma
-are tumors of fibrous or connective tissue that can grow in any organ. Fibroids commonly grow in the uterus.
2. Lipoma
- a slow-growing, fatty lump that is most often situated between the skin and the underlying muscle layer.

3. Leiomyoma
- smooth muscle in origin
- rarely becomes malignant (1% of case)

Malignant Tumors

Carcinoma – epithelial tissue

Sarcoma – mesenchymal origins (bld. Vessels, lymphatics, nerve tissue)

1. Carcinoma in Situ
- neoplasm of epithelial tissue that remains confined to the site of origin

3. Malignant Fibrosarcoma
- may originate from benign fibromas
-bulky, well differentiated tumor
- rarely metastasize

4. Bronchogenic Carcinoma
- 90% of all cases of lung CA
- usually develops in lower trachea and lower bronchi
-when there is metastasis: surgery contraindicated

Adeno – glandular tissue

Angio – blood vessels
Basal cells – epithelium, mainly sun exposed area
Embryonal – gonads
Lympho – lymphoid tissue
Melano – pigmented cells of epithelium
Myo- muscles
Osteo - bone

CLASSIFICATION OF NEOPLASM
Tissue of Origin Benign Malignant
 Connective Tissue Fibroma Fibrosarcoma
Fibrous Tissue Lipoma Liposarcoma
Adipose Tissue Osteoma Osteogenic sarcoma
Bone
 Epithelium Papilloma Squamous cell carcinoma
Skin Leukemia
Bone Marrow Multiple myeloma
 Muscle Tissue Leiomyoma Leiomyosarcoma
Smooth muscle
 Nerve Tissue Neuroma Neurogenic sarcoma
Nerve fibers Meningioma Malignant meningioma
Meninges
 Gonads Dermoid cyst Embryonal carcinoma

Cancer Classification: GRADING & STAGING

I. Grading
-according to histologic or cellular characteristics of tumor

Histopathology:
Gx - grade cannot be assessed
G1 - well differentiated grade
G2 - moderately well differentiated grade
G3 - poorly differentiated
G4 - undifferentiated

II. Staging
- it quantifies the disease or identify the spread of disease

T – stands for the extent of primary tumor N – involvement of regional lymph nodes M – extent of
metastatic involvement

TNM Classification System:

Tx - tumor cannot be adequately assessed
 T0 - no evidence of primary tumor
TIS - Carcinoma in situ
T1T2T3T4- progressive increase in tumor size and/ or involvement

Nx - regional lymph nodes cannot be assessed clinically

No - no evidence of regional node
N1N2N3- increasing involvement of regional lymph nodes

Mx - not assessed
Mo - no distant metastasis
M1M2M3- ascending degree of distant metastasis

eg. BREAST CANCER

TUMOR
Tx- primary tumor cannot be assessed
T0- no evidence of primary tumor
Tis- carcinoma in situ
T1- tumor 2 cm or less
T2- tumor more than 2 cm but not more than 5 cm
T3- tumor more than 5 cm
T4- tumor of any size with direct extension to chest wall or skin

REGIONAL LYMPH NODE

Nx- regional lymph nodes cannot be assessed
N0- no regional lymph node metastasis
N1- metastasis to movable ipsilateral axillary lymph node
N2- metastasis to ipsilateral axillary lymph node fixed to each other or other structures
N3- metastasis to ipsilateral internal mammary lymph node

DISTANT METASTASIS
Mx- presence of distant metastasis cannot be assessed M0- no distant metastasis
M1- distant metastasis present (includes metastasis to ipsilateral supraclavicular lymph nodes
Stage 0- Tis, N0, M0
Stage 1- T1, N0, M0
STAGE GROUPINGS
Stage IIA- T0, N1, M0; T1, N1, M0; T2, N0, M0
Stage IIB- T2, N1, M0; T3, N0, M0
Stage IIIA- T0, N2, M0; T1, N2, M0; T2, N2, M0; T3, N1, M0; T3, N2, M0
Stage IIIB- T4, any N, M0 or any T, N3, M0
Stage IV- any T, any N, M1

COMPARISON BETWEEN BENIGN AND MALIGNANT NEOPLASM

CHARACTERISTICS BENIGN NEOPLASM MALIGNANT NEOPLASM

Spread of Growth Grows slowly, usually Usually grows rapidly, tends to
continues to grow throughout grow relentlessly throughout
life unless surgically removed; life; rarely, neoplasm may
may have periods of remission regress spontaneously
Mode of Growth Gros by enlarging and Grows by infiltrating
expanding; always remains surrounding tissues; may
localized; never infiltrated remain localized (in situ) but
surrounding tissues usually infiltrates other tissues
Capsule Almost always Never contained within
contained within a fibrous a capsule; absence of capsule
capsule; capsule does not allows neoplastic cells to
prevent expansion of neoplasm invade surrounding tissues;
but does prevent growth surgically removal of tumor
by infiltration; capsule difficult
advantageous because
encapsulated tumor can
be removed surgically
Cell Characteristics Usually well differentiated; Usually poorly differentiated;
mitotic figures absent or large numbers of normal and
scanty; mature cell; anaplastic abnormal mitotic figures
cells absent present; cells tend to be
anaplastic
Recurrence Recurrence extremely Recurrence common following
unusual when surgically surgery because tumor cells
removed spread into surrounding
tissues
Metastasis Metastasis never occur Metastasis very common
Effect of Neoplasm Not harmful to host Always harmful to host, results
unless located in area in death unless removed
where it causes surgically or destroyed by
compression of tissue or radiation or chemotherapy;
obstruction of vital causes disfigurement,
organs; does not disrupted organ function, and
produce cachexia nutritional imbalances
Prognosis Very good; tumor generally Depends on cell type and
removed surgically speed of diagnosis; poor
prognosis indicated if cells are
poorly differentiated and
evidence exists of metastatic
spread; good prognosis
indicated if cells still resemble
normal and there is no
evidence of metastasis

GENERAL CLINICAL MANIFESTATION OF CANCER:

I. PAIN
Types of cancer pain:

A. Acute pain-usually starts suddenly

B. Chronic pain – usually lasts more than 6 months
Nursing Responsibilities:
⚫ Help patients and families to take an active role in managing pain.
⚫ Provide education and support to correct fears and misconceptions about opioid use.

II. Bleeding
Nursing Responsibilities:
⚫ Encourage to use a soft, not stiff, toothbrush and an electric not straight edged, razor to prevent bleeding
⚫ Provide soft foods, increase fluid intake and stool softeners, as ordered
⚫ Handle and move joints and extremities gently to minimize risk for spontaneous bleeding
⚫ Serum hemoglobin and hematocrit are monitored carefully for changes indicating blood loss.
⚫ The nurse tests all urine, stool, and emesis for occult blood.
⚫ Neurologic assessment.
⚫ Administers fluid and blood products as ordered
⚫ Vasopressor agents are administered as prescribed to maintain blood pressure and ensure tissue oxygenation

III. Infection- Streptococcus and staphylococcus species

Nursing Responsibilities
⚫ Administer antibiotics promptly.
⚫ Strict asepsis.
⚫ Encourage appropriate hygiene.
⚫ Encourage patient to cough and perform deep breathing exercises
 .

IV. Anorexia-Cachexia Syndrome

Nursing Responsibilities
⚫ Food should be prepared in ways that make it appealing.
⚫ Unpleasant smells and unappetizing looking foods are avoided.
⚫ Provide small, frequent meals.
⚫ Encourage oral hygiene before mealtime to make meal more pleasant.
⚫ If adequate nutrition cannot be maintained by oral intake, nutritional support via the enteral route.

DETECTION AND PREVENTION OF CANCER:

I. Primary Prevention Measures- ideal method of preventing cancer.
 1. Optimal Dietary Patterns and Lifestyle Changes
-dietary factors are related to 50% of all environmental cancers.
-avoid obesity
- practice moderation in consumption of salt-cured, smoked and nitrate-cured foods
- fresh vegetables
- increase fiber intake (beans, broccoli, berries, avocado, popcorn, whole grains, apples)
- increase vit. A (dairy products, liver, fish, carrots, broccoli, cantaloupe, and squash)
- increase foods rich in Vit.C (Broccoli, Brussels sprouts, cauliflower, Green and red peppers, Spinach,
cabbage, turnip greens, and other leafy greens. Sweet and white potatoes. Tomatoes and tomato juice.
Winter squash.)
- increase Vit. E
Vegetable oils (such as wheat germ, sunflower, safflower, corn, and soybean oils)
Nuts (such as almonds, peanuts, and hazelnuts/filberts)
Seeds (such as sunflower seeds)
Green leafy vegetables (such as spinach and broccoli)
- reduce alcohol intake (red wine is okay occasionally)

2. Minimize exposure to Carcinogens

- stop smoking
- avoid exposure to asbestos fiber and constant environmental dust
- avoid exposure to chemicals
-avoid radiation exposure
- avoid overexposure to the sun

3. Obtain adequate rest and exercise to reduce stress

II. Secondary Prevention- Early Detection

A. Health history and PE B. Screening

Methods
1. Mammography, Pap Smear, Prostate exam, digital rectal exam

⚫ Mammography- radiographic technique used to detect breast cyst and tumor especially
those not palpable on physical examination.
Responsibilities:
1. No mammogram for a week before monthly period.
2. No deodorant, talcum powder or lotion under arms or breast on the day of the test.

⚫ Pap smear- or pap test, cervical smear, smear test

⚫ Prostate exam
- during examination, patient will stand and feet apart
- normally prostate is 2-4 cms long, triangular in shape, firm and rubbery.
⚫ Digital rectal exam (sims lateral position)
 2. Self-care practices

2.1. Breast Self-Exam- women should be told about the benefits and limitations of BSE. The
importance of prompt reporting of any new breast
symptoms to a health professional should be emphasized.

2.2. Testicular exam- it is best to do a TSE during or right after a hot shower or bath.

Procedure:
Examine one testicle at a time.
Use both hands to gently roll each testicle (with slight pressure) between your fingers. Place your thumbs
over the top of your testicle, with the index and middle fingers of each
hand behind the testicle, and then roll it between your fingers.
You should be able to feel the epididymis (the sperm-carrying tube), which feels soft, rope-like, and
slightly tender to pressure, and is located at the top of the back part of each testicle.
⚫ When examining each testicle, feel for any lumps or bumps along the front or sides.
Lumps may be as small as a piece of rice or a pea.

3. Sigmoidoscopy and fecal occult blood test- annual flexible sigmoidoscopy and FOBT every 5
years, starting at age 50 years

Teaching
Early Warning Signs of Cancer

⚫ Change in bowel or bladder movement

⚫ A sore / wound that does not heal
⚫ Unusual bleeding or discharge
⚫ Thickening of breast/lump
⚫ Indigestion / dyspepsia
⚫ Obvious change in wart or mole
⚫ Nagging/ hoarseness
⚫ Unexplained weight loss / Loss of appetite
⚫ Prolonged anemia

Diagnosis of Cancer and Related Nursing Consideration:

⚫ Patients with suspected cancer undergo extensive testing to:

⚫ Determine the presence of tumor and its extent.
⚫ Identify possible spread of disease or invasion of other body tissues.
⚫ Evaluate the function of involved and uninvolved body system and organs.
⚫ Obtain tissue and cell of analysis, including evaluation of tumor stage and grade.

Nursing Responsibilities:

⚫ Help relieve fear and anxiety.

a. Explaining the tests to be performed.
b. The sensations likely to be experienced.
c. Patient’s role in the test procedures.

https://youtu.be/UCNx78zIrwU ( URL- Grading and Staging)

https://youtu.be/2OUkQrYHgSU ( URL- Mammogram)

 Diagnostic Tools in Detecting Cancer

1. Laboratory Tests
-can be used to diagnose a specific organ dysfunction or metabolic aberration that may be caused by
malignant condition.

◼ CBC & Differential count

Increase in WBC – Acute Lymphocytic Leukemia (ALL)
Decrease in RBC – Aplastic Anemia
Increase in Alkaline Phosphate – Osteogenic CA

◼ Serum Electrolytes
Ca – increase suggestive of bone metastasis
Na – decrease suggestive of Bronchogenic
CA K – decrease suggestive of Liver CA

◼ Examination of body fluids (sputum & Urine)

◼ Tumor Markers or Proteins associated with specific cancer- marker used to monitor response to
antineoplastic treatment and to determine the client’s prognosis in a
variety of cancer. Example:
1. Serum prostate- specific antigen (PSA)- proteins produced by cells of the prostate gland.
Normal value: less than 4.0 ng/ml (nanogram/ml)
2. Alpha-fetoprotein (AFP)- increase level in the blood suspects certain cancer of the liver, testes or
ovaries. Normal value: less than 10 ng/ml.
3. Carcinoembryonic Antigen (CEA)- increase level may suggest colon cancer.
Blood sample will be taken. Normal value: less than 2.5 ng/ml.
4. Homovanillic Acid (HAV)- produced by metabolism of dopamine
-elevated result may be associated with tumors of adrenal gland
-normal accumulation in 24 hr. urine collection = 0 to 15 mg
5. Vanillylmandelic Acid (VMA)- urinary metabolite of epinephrine and norepinephrine
-24 hr. urine collection normal value = 1.5 to 7.5 mg (adult)
83 mg/kg of BW (infants)
-increased in tumors of adrenal gland and nervous system
6. B-Human Chorionic Gonadotropin (B-HCG)- hormone normally found in blood and urine during
pregnancy.
-used to diagnose trophoblastic disease, germ cell tumors of testes and ovaries
7. Adrenocorticotropic Hormone (ACTH)- measures the level of ACTH in blood to check problems in
pituitary and adrenal gland.
◼ Urine
Bence Jones CHON – urine study; test is done to diagnose or monitor presence of multiple myeloma.

Photograph of Bence-Jones protein crystals from a human cancer patient

◼ Stool
Guaiac Test – occult blood; test to find hidden blood in the stool to determine GI
bleeding.

Radioimmunoassay – technique that measures tumor antigen in the serum using radiolabeled antigens.

Flow Cytometry – identifies cellular and DNA characteristics of the tissue that may yield important
diagnostic and prognostic information
-developed at Los Alamos
-it is a method of counting thousands of cells per second.
-cells are tagged with a marker that lights up, or fluoresces, when it and its host cell pass through the
brilliant light of a laser beam. The markers are often artificial antibodies
that bind to proteins found only on the cells of interest.
-the tagged cells are suspended in fluid and run through the cytometer, which sends them single file
through the laser beam, where they light up.
- detector sees the fluorescent light and tells the computer, which tallies the number of
tagged cells.

2. Cytologic Examination
◼ Papanicolaou Test (Pap Smear)
- screening test that examines cervical scrapings for abnormality.
- It is used to diagnose cancer in an asymptomatic person and to identify precancerous
lesions or noninvasive cancer.
- It is used to detect inflammation, infection, premalignant changes, and malignancy of the cervix
Procedure:
⚫ Using a vaginal speculum to enhance visibility, the physician or nurse practitioner
collects the patient’s secretions and cells from the cervix and vagina.
⚫ The fluid and tissue scrapings are placed on glass and sprayed with or immersed in a fixative.

Exfoliative Cytology
- used to analyze pap smear

Bethesda System Classification

Class I Normal
Class II Inflammation
Class III Mild to Moderate Dysplasia
Class IV Probably Malignant
Class V Malignant (if malignant the next dx is colposcopy)

3.Oncologic Imaging

◼ Radiographs/ X-ray
⚫ Chest X-ray- makes images of the heart, lungs, airways, blood vessels, bones of the spine and
chest.
⚫ Mammogram- radiographic test used to detect breast cyst and tumor especially
those nor palpable on physical examination.

⚫ CT Scan- x-ra technique that produces sequential cross section of body images at progressive
depths.
Responsibilities:
a. Wear loose fitting clothing or gown.
b. No jewelry, dentures or hairpins.
c. Not to eat or drink several hours before the test if with contrast medium. Check for
allergy.
d. Female patients should not be pregnant.
e. Remind patient to keep still during the procedure.
f. Sedatives may be given as ordered for claustrophobic patients.
g. Patient may hear slight buzzing or clicking during the procedure.

⚫ MRI- identifies abnormalities by creating cross sectional image of the body, does not require
ionizing radiation.
Responsibilities:
a. No jewelry, pins, hairpins, pacemaker, cochlear implants or metal objects.
b. Sedatives may be given as ordered for claustrophobic patients.
c. Procedure may be done with contrast medium, check for allergies.

◼ Positron Emission Tomography (PET)- studies glucose metabolism in body tissues and is proving
useful in differentiating varying rates of tissue metabolism.
- injection of a small dose of radioactive chemical called radiotracer. Responsibilities:
a. Tell patient to remain still during the procedure.
b. NPO at least 6 hours before the test.
c. Female patients should not be pregnant.

4.Biopsy- the only definitive way to diagnose cancer. It is essential to obtain and accurately identify
an adequate tissue sample before any cancer therapy is prescribed.

5. Endoscopy- fiberroptic tubes equipped with a light source are commonly used to illuminate
various body cavities, permitting visual inspection of the interior of the cavity being
examined.
 CA SOCIETY RECOMMENDATION FOR EARLY DETECTION OF CANCER IN ASYMPTOMATIC
PERSONS
TEST SEX AGE FREQUENCY

MAMMOGRAPHY F 35-40 1 baseline study

PAP SMEAR F 18 up every year
PROSTATE M 50 up every year
DRE M/F 40 up every year
BSE F 18 up every month
SIGMOIDOSCOPY M/F 50 up every 3-5 years
FECAL OCCULT M/F 60 up every year

Management of Patient with Neoplastic Diseases:

Goals:
1. Complete eradication of malignant disease (cure)
2. Prolonged survival and containment of the cancer cell growth (control)
3. Relief of symptoms associated with the disease (palliation)

⚫ SURGERY- is the most frequently used treatment modality in cancer.

* Diagnostic Surgery: 3 Methods

a. Excisional biopsy – most frequently used for easily accessible tumors of the skin, breast, and upper
or lower gastrointestinal and upper respiratory tracts.
b. Incisional biopsy – performed if the tumor mass is too large to be removed.
c. Needle biopsy – used to sample suspicious masses that are easily accessible such as some
growths in the breasts, thyroid, lung, liver, and kidney. Needle biopsies are most often performed on
an outpatient basis.

* Surgery as Primary Treatment

Goal: TO remove the entire tumor or as much as possible and any involved surrounding tissue,
including regional lymph nodes.

2 Common Procedures:
⚫ Local incision
⚫ Wide or Radical Excision

New Approaches: SURGERY AS PRIMARY TX

A. Video – assisted endoscopic surgery- is fast replacing surgeries associated with long incisions and
extended recovery periods.
Procedure:
1. An endoscope with intense lighting and an attached multi-chip mini camera is inserted through a
small incision into the body.
2. The surgical instruments are inserted into the surgical field through one or two additional small
incisions, each about 3cm long.

3. The camera transmits the image of the involved area to a monitor so the surgeon can manipulate the
instruments to perform the necessary procedure.

B. Salvage surgery
- is an additional treatment option that uses an extensive surgical approach to treat recurrence of
the cancer after a less extensive primary approach is used

Ex. Mastectomy

C. Electrosurgery- makes use of electrical current to destroy the tumor cells.

D. Cryosurgery – uses liquid nitrogen to freeze tissue to cause cell destruction.

E. Chemosurgery – this uses combined topical chemotherapy and layer by layer surgical removal of
abnormal tissue.

F. Laser Surgery – makes use of light and energy aimed at an exact tissue location and depth to
vaporize cancer cells.

G. Stereotactic Radiosurgery – is a single and highly precise administration of high dose radiation
therapy used in some types of brain and head and neck cancer.

Other forms of Surgery:

⚫ Prophylactic Surgery
– involves removing non vital tissues or organs that are at increased risk to develop cancer.

⚫ Palliative Surgery – make the patient as comfortable as possible and to promote quality of life as
defined by the patient and his or her family.

Goal: to make the patient as comfortable as possible and to promote a satisfying and productive life
for as long as possible.

⚫ Reconstructive Surgery
– may follow curative or radical surgery and is carried out in an attempt to improve function or
obtain a more desirable cosmetic effect.

Nursing Management in Cancer Surgery

⚫ Complete a thorough pre-operative assessment for all factors that may affect the patients who will be
undergoing surgery.
⚫ Provide education and emotional support by assessing patient and family needs and exploring with the
patient and family their fears and coping mechanism.
⚫ Communicate frequently with the health team members to be certain that the information provided is
consistent.
⚫ Assess the patient’s responses to the surgery and monitor possible complications.
⚫ Provide comfort.
⚫ Initiate as early as possible plans for discharge, follow-up and home care and treatment to ensure
continuity of care.
⚫ Patients and family are encouraged to use community resources such as the
Philippine Cancer Society.

RADIATION THERAPY

- it is the use of ionizing radiation to interrupt cellular growth.

- may also be used to control malignant disease when a tumor cannot be removed surgically or when local
nodal metastasis is present, or it can be used neoadjuvant with or without chemotherapy to reduce the size
of a tumor to enable surgical resection.

Radiation therapy may be used prophylactically to prevent the spread of a primary cancer to a distant area.

Indications:

⚫ To cure cancer.
⚫ To control malignant disease when a tumor cannot be removed surgically or when local nodal
metastasis is present.
⚫ Prophylactic use
⚫ Palliative use.

2 Types of Ionizing Radiation

⚫ Electronic Rays (x-rays and gamma rays)

Gamma rays- to protect self you need a shield at least as thick as concrete wall
-most penetrating type
X-ray- less penetrating than gamma rays
Alpha particles- can be shielded by a sheet of paper or by human skin
Beta particles- cannot be stopped by a sheet of paper or human skin, needs thicker shield like wood to
stop them
⚫ Particles – electrons, beta particles, protons, neutrons and alpha particles.

Effects of Radiation Therapy:

⚫ Alters the DNA molecule within the cells of the tissue and breaks the strands of the
DNA helix, thus causing cell death.
⚫ It ionizes constituents of body fluids, especially water that results in the formation of free radicals and
irreversibly damaging the DNA. Cells may die immediately or it may initiate cellular suicide (Apoptosis).

Commonly Transported Radioisotopes:

⚫ Americium-241= Diagnose thyroid disorders, smoke detectors.
⚫ Cesium-137= Cancer treatment.
⚫ Iodine-125,131= Diagnosis & treatment liver, kidney, heart, lung and brain.
⚫ Technetium-99m=Bone and brain imaging; thyroid and liver studies; localization of brain tumors.

Radiation Measurement Terminology:

Exposure rate = amount radiation possible to receive per unit time. Dose = total
amount of radiation received.

2 Types of Radiation Therapy:

A. External Radiation or teletherapy

- is used depending on the size, shape, and location of the tumor. Different energy levels are generated to
produce a carefully shaped beam that will destroy the targeted tumor, yet spare the surrounding healthy
tissue and vital organs in an effort to reduce the treatment toxicities for the patient.

Kinds of Teletherapy:

1. Kilovoltage therapy device

– delivers the maximal radiation dose to superficial lesions such as lesions of the skin and breasts.

2. Linear Accelerators and betatron machines – produce high x-rays and deliver their dosage to deeper
structure with less harm to the skin and less scattering of radiation within the body tissues.
3. Gamma Rays – are produced from spontaneous decay of naturally occurring radioactive elements
such as Cobalt 60; deliver radiation dose beneath the skin surface, sparing skin tissue from
adverse effects.

4. Particle beam radiation therapy (High Linear Energy) – transfer radiation accelerates sub
atomic particles(neutron, pions, heavy ions) through body damaged target cells as well as cells
in its pathways.

5. Intraoperative radiation therapy (IORT) – involves delivering a single dose of high- fraction radiation
therapy to the exposed tumor bed while the body cavity is open during surgery.

IMPLEMENTATION

1. Offer psychological support and teaching

What to expect:

⚫ commonly asked questions

⚫ Painful?
⚫ What will I ask to do during my therapy?
⚫ What happens during the actual intervention?
⚫ Will I be left alone during my intervention?
⚫ What if I become sick during my therapy and need help? What should I do?

2. Diet – increase CHON, CHO, increase fluids (NPO several hours before treatment)

3. Medication
Compazine-nausea

3. Skin care

⚫ Radiodermatitis- inflammation of the skin after exposure to radiation (dry, infection is

common)
- wash with water, pat dry
-avoid exposure to sun
-do not remove lines or ink marks
-wear loose-fitting clothing
-shave with electric razor
⚫ Wet reaction or desquamation- weeping of the skin due to the loss of upper layer, develops 2-3
weeks after, heals 4-6 week
Implications:
⚫ Promote rest after therapy.
⚫ Cleanse area with water, pat dry.
⚫ Apply antibiotic lotion as ordered.
⚫ Expose site to air.
B. Internal Radiation Implantation or Brachytherapy
- it delivers a high dose of radiation to a localized area. The specific radioisotope for implantation is
selected on the basis of its half-life, which is the time it takes for half of its radioactivity to decay. Internal
radiation can be implanted by means of needles, seeds, beads, or catheters into body cavities or interstitial
compartments.

2 Kinds of Implants:

⚫ Sealed
⚫ Unsealed

2 Types of Radioisotopes:

◼ Intracavity Radioisotope - is frequently used to treat gynecologic cancers. In these malignancies, the
radioisotopes are inserted into specially positioned applicators after their placement is verified by x-
ray.
- Uses Cesium137 or Radium226.

Nursing Considerations:

⚫ Remain in place for prescribed period and then are removed, generally 24-72 hours.
⚫ Patients are maintained on bed rest and log rolled.
⚫ An indwelling catheter is inserted.
⚫ Low residue diets and anti-diarrheal agents, such as diphenoxylate (Lomotil)

◼ Interstitial Radioisotopes- used in treating prostate, pancreatic or breast cancer.

- it may be temporary or permanent, depending on the radioisotope used which usually consists of
seeds, needles, ribbons, beads, wires or small catheters positioned to provide a local radiation
source and less frequently dislodged.

Ex. Iridium192, iodine125, Cesium137, Gold198 and Radon222

Principle of Radiation Protection – depends on 3 factors

⚫ The distance between the nurse and the patient.

⚫ The amount of time spent in actual proximity to the patient
⚫ The degree of shielding provided
Precautionary measures:

⚫ Place patient in a private room.

⚫ Place a sign on the patient’s door and on the patient’s, chart indicating that the
patient is receiving internal radiation therapy.
⚫ Observe principles of time and distance.
⚫ Check all linens, bedpans and emesis basin routinely to see if the sealed source has been accidentally
lost from the tissue.
⚫ If sealed source is dislodged, but has not fallen out of the patient’s body,
notify the x-ray radiation department at once.
⚫ If fallen out, do not pick it up with bare hands. Use forceps and place it in a lead container.
⚫ Most patients are placed on bed rest and instructed to remain in certain positions so
that the emanations from the element will reach the correct area.
⚫ Visitors will spend limited time in the room to 30 minutes daily, seeing that visitors maintain a 6-foot
distance from the radiation source.
⚫ Prohibit visits by children or pregnant visitors.

Special precautions – Patient receiving internal radiation therapy from an unsealed source:
⚫ Observed the principles of time, distance and shielding for radiation protection.
⚫ Wear gloves when handling bedpans, bed linens and patient’s clothes.
⚫ Dispose of urine, feces and vomitus according to policy.
⚫ Handle dressings with forceps and dispose of them according to policy.
⚫ Follow hospital procedure for disposal of patient’s bed linens and clothing.

Common Side Effects of Radiation Therapy

External Radiation

Head and Neck

⚫ irritation of oral mucous membranes with oral pain and risk of infection.
⚫ Loss of taste.
⚫ Irritation of the pharynx and esophagus with nausea and indigestion.
⚫ Increase intracranial pressure.

Chest
- Inflammation of lung tissue with increase susceptibility to infection.

Abdomen
- nausea, vomiting, diarrhea, anorexia

Pelvis
- diarrhea, cystitis, sexual dysfunction, Urethral and rectal stenosis

General Side Effects:

SKIN: change in texture and/or color, moist desquamation(rare); alopecia
BLOOD: bone marrow depression with leucopenia, anemia and thrombocytopenia. Depressed
Immune Function
Fatigue

Internal Radiation
General Effects:
1. Elevated temperature.
2. Cervical implant: Urinary frequency, diarrhea, nausea, vomiting and anorexia.
3. Head and Neck: mucositis, oral pain and risk for infection, anorexia.

Skin Care Treatment

⚫ Apply the special skin care lotion four times a day, starting immediately.
⚫ Do not wash off treatment markings. Tattoos, if done, are permanent.
⚫ Keep skin clean and dry. Expose the skin to air as much as possible.
⚫ Protect the skin in the treatment area from the sun and cold by using scarves, hats or other clothing.
⚫ Cornstarch may be used for dry, itchy skin.
⚫ Irritated skin, a different lotion may be needed.
⚫ Bathing – clear water and pat dry. Use mild soap.
⚫ Clothing: wear soft, loose cotton clothing over the treatment area.
⚫ Shampooing – use baby shampoo.
⚫ Shaving – use electric razors.
⚫ Do not rub or scratch the skin in the treatment area.
⚫ Do not use lotions or creams not approved by the doctor.
⚫ Do not use deodorants, perfumes or make-up in the treatment area.
⚫ Do not use ice packs or heating pads
⚫ Do not use tape in the treatment area.

Post Removal of Source

⚫ Betadine douche
⚫ Enema
⚫ Out of bed
⚫ Avoid direct sunlight
⚫ cream
⚫ Resume Sexual intercourse within 7-10 days

Factors affecting the side effect of Radiation Therapy:

⚫ body site irradiated

⚫ radiation dose
⚫ extent of body area treated
⚫ method of radiation therapy

https://youtu.be/E44W54z_Ykw (URL- MRI)

https://youtu.be/-xL4qPBH48U (URL- CT SCAN)

https://youtu.be/6F3gNFL5IL8 ( URL- Cryotherapy)

https://youtu.be/7ScVu-ZGfu8 ( URL- Stereotactic/ Gamma Knife)
https://youtu.be/rzNzNBqay5k (URL- Teletherapy)
https://youtu.be/MZRfzLQb92A ( URL- Brachytherapy)